Provider Demographics
NPI:1386113280
Name:DOROTHY COVERSON FOUNDATION
Entity type:Organization
Organization Name:DOROTHY COVERSON FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:RAMON
Authorized Official - Last Name:POLLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-324-2126
Mailing Address - Street 1:3075 E FLAMINGO RD STE 118
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-4300
Mailing Address - Country:US
Mailing Address - Phone:702-522-7363
Mailing Address - Fax:702-920-8322
Practice Address - Street 1:3075 E FLAMINGO RD STE 118
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-4300
Practice Address - Country:US
Practice Address - Phone:702-522-7363
Practice Address - Fax:702-920-8322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV=========Medicaid